Microsoft word - ct screening form.doc

First Name:__________________________ M.I. _____ Last Name:____________________________ Male / Female D.O.B:_________________ Employer: _____________________________ MARRIED / SINGLE / OTHER Home Phone: _______________________ Cell: _____________________ Work: ________________________
Address: ____________________________City/State/Zip Code: _____________________________________________
Primary Cardholder’s Name on Insurance: ________________________________ Relation: Self / Spouse / Child
Subscribers D.O.B: __________ Subscribers Employer:___________________________ SS#:_____________________
Please answer the following questions. For your safety, please circle Yes or No and answer completely:
Have you had a prior CT scan that pertains to today’s exam and where? ________________________________________
What medications do you currently take?________________________________________________________________
What is your weight? ____________________________
List any surgeries?__________________________________________________________________________
Yes No Are you Allergic to Iodine? List all Drug/Food Allergies you have:
__________________________________________________________________________________________________
Yes No Have you had any IV contrast within the past 48 hours? ________________________________
Yes No Do you have both kidneys? ______________________________
Yes No History of Kidney Surgery? ______________________________
Yes No Asthma or Lung problems? ______________________________
Yes No Hepatitis or Jaundice? __________________________________
Yes No Epilepsy/Seizures? _____________________________________
Yes No High Blood Pressure (hypertension)? _______________________________________________
Yes No Heart Problems? _______________________________________________________________
Yes No History of Cancer; If yes, explain:___________________________________________________
Yes No Stomach/Intestinal Problems; If yes, explain: __________________________________________
Yes No Multiple Myeloma; If yes, explain: __________________________________________________
Yes No Stroke; If yes, explain: ___________________________________________________________
Yes No Bladder Problems; If yes, explain: __________________________________________________
Yes No Metal Implants/Foreign Objects; If yes, explain: _______________________________________
Yes No DIABETIC OR RENAL DISEASE? _____________________________________________________
WHAT ARE YOUR SYMPTOMS? ______________________________________________________________
If Diabetic, do you take Metformin Medications (Glucophage, Glucovance, Avadament, Metaglip, Fortamet, or Riomet)?
If YES, please DO NOT TAKE YOUR METFORMIN MEDICATIONS FOR 48 HOURS AFTER RECEIVING IODINE CONTRAST INJECTION.
PLEASE NOTIFY YOUR PHYSICIAN FOR ADVISEMENT*******************************************
FOR FEMALE PATIENTS OF CHILD BEARING AGE; COMPLETE THE FOLLOWING: Please check all that apply; if none please complete below information: I have had a Hysterectomy I have had a tubal ligation Are you Pregnant? Yes / No Are you Nursing? Yes / No Birth Control Information (If Applicable): My birth control method is ___________________________. The dates of my last menstrual cycle are/were ___________________ to _______________________. Consent: I have answered all the questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that I am NOT pregnant at this time. Patient Signature: _______________________________________________ Date: ____________________________ ________________________________________________________________________________________________ FOR TECH USE ONLY: CREATININE _____________ IV SITE: ___________ GAUGE: ___________ TECH: ____________

Source: http://www.touchstoneimaging.com/Uploads/Files/Downloads/CT%20Screening%20Form.pdf